Patterns of practice in internal medicine in Ontario J.K. MCCONNON, MD, CH B, FRCP[C], FACP; C.P. SHAH, MB, DCH, MRCP (GLAS), FRCP[C], M SC (IIYG)
To determine the feasibility of wholly referral practice In Internal medicine within a prepaid health service, the practice profiles of 694 InternIsts in metropolitan, nonmetropolitan urban, and rural areas of Ontario were delineated by analysis of data from questionnaires and health-insurance billing. The questionnaire showed that two thirds of internists, chiefly younger practitioners, confined themselves to a referral consultant practice; the other one third included primary care. Subspeciallsts practised predominantly in metropolitan areas; most general internists in such areas provided primary care, whereas most general internists elsewhere had an entirely referral practice. This pattern of practice is greatly different from that in the United States but probably similar to that in other provinces in Canada. Extension of wholly referral practice to all Internists in Ontario appears feasible, provided the numbers entering residency training are controlled. The present Ontario curricula for internal medicine and its subspecialties appear suitable for such a pattern of practice.
avalent une pratique enti.rement composee de consultation sur reference. Ce sch6ma de pratique est sensiblement different de celui rencontr. aux .tats.Unis, mais ii est probablement semblable a celul des autres provinces du Canada. L.extension a tous les internistes de l.Ontario d.une pratique de consultation sur reference seulement semble r6alisable en autant que le nombre de medecins residents solt contr8le. Le pr6sent curriculum exige en Ontario pour Ia m6decine interne et ses sous-specialites semble se pr.ter a une telle pratique.
areas without medical schools, including some cities. We analysed OHIP billing data for 1972-73 and 1973-74 to determine the mean number of services provided by, and annual payment to, internists in the three areas. A service was defined as any single item, varying from consultation or minor assessment to a specific procedure, such as electrocardiography. We applied the fee-schedule terms used by OHIP, in some cases combining categories for simplicity. Definitions were as follows: Consultation (including reconsultation): referral of a patient to another physician for a written opinion. General assessment (including Formulating plans for residency train- sessment): full medical history reasand ing in internal medicine in Canada is complete examination; not necessarily a difficult because of uncertainty about referral. the theoretically desirable pattern of Specific assessment (including practice for internists and the lack of sessment): history relating to, andreasexdata on present practices. Some have amination of, any part, region or syssuggested that specialists in Canada tem; not necessarily a referral. should have referral practices only,1-3 Minor or partial assessment, or subas in Britain, whereas American authors sequent visit, or both: not necessarily advocate primary care as a major role a referral. of the internist.4-10 To determine whethLaboratory tests and procedures: (a) er changes are needed requires knowl- diagnostic radiology, including edge of current practice, as is evident medicine investigation and testsnuclear from the report of the National Com- times performed by internists some(e.g., Afin de determiner Ia possibilit6 d'une mittee on Physician Manpower in pratique de medecine interne compos6e Canada.11 We therefore questioned fluoroscopy and angiography); (b) manual tests (e.g., routine extotalement de patients r6f6r6s a practising internists in Ontario and amination of 24-hour urinalysis, collection of lint6rieur d'un service de soins de studied their billing to the Ontario urine for 1 7-hydroxycorticosteroids and sante pay6 d.avance, les types de Health Insurance Plan (OHIP). interpretation of bone marrow films); pratique de 694 internistes des (c) automated tests; and (d) radioisotope r6gions metropolitalnes, urbaines Methods therapy. nonmetropolitaines, et rurales de Procedures: (a) nonsurgical (e.g., l'Ontario ont ete etablis par l.analyse Distribution and workload of internists cervical smear); (b) surgical (e.g., colonde donnees recuelilies par questionnaire oscopy polypectomy); (c) specific et de celles obtenues a partir du To derive ratios of population to internal and medicine procedures (e.g., systeme de facturation de l'assurance number of internists (excluding neurol- pleural tap and arterial blood-gas sante. ogists) and to number of general pracLe questionnaire a r6v616 que deux titioners, we defined a general practi- sampling); and (d) electrocardiography. tiers des internistes, les medecins tioner as a physician without specialist les plus jeunes surtout, se limitalent qualification from the Royal College Profiles of internists a une pratique de consultation sur of Physicians and Surgeons of Canada. A questionnaire was sent to the 975 ref6rence; I.autre tiers offrait aussi We determined the numbers of intern- internists listed in the 1975 "Ontario les premiers soins. Les internistes ists and general practitioners from the Medical Directory"13 asking sex, age, offrant une sous-specialisation 1973 "Ontario Medical Directory". date of certification and number of pratiquaient principalement en region and derived ratios to the general pop- years of practice; country of graduametropolitaine; les internistes generaux ulation from the latest available (1971) tion and of graduate training; geode ces regions offraient les premiers Government of Canada census. graphic location of practice (metroposoins, alors que Ia plupart des Ontario has a population of over 7 litan [within the boundaries of the five Internistes g6neraux des autres regions million; nearly all residents are covered university cities] or nonmetropolitan); by OHIP. OHIP divides the province type of practice (70% or more of into nine units: Toronto (population, workload in private practice, university over 2 million), including surrounding appointment or agency practice); and From the departments of medicine, preventive districts, which has the largest medical nature of practice (primary care, remedicine and biostatistics, and health administration, University of Toronto; Peel school in Ontario; four other medical- ferred work in internal medicine or a Memorial Hospital, Brampton; and the Hospital for Sick Children, Toronto school areas, including the cities subspecialty, or continuing care for (Hamilton, Kingston, London and Ot- chronic conditions with or without the Reprint requests to: Dr. J.K. McConnun, 164 Queen St., Brampton, Ont. L6V 1B4 tawa) and surrounding areas; and four help of a general practitioner) and the CMA JOURNAL/JUNE 4, 1977/VOL. 116
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Table I-Ratios of numbers of internists (I) and general practitioners (GP) to population, and l:GP ratio, OntarIo, 1973
Area Toronto Other medical-school Without medical schools Total/average
Population, 1971 2 086 020 3 443 450 2 173 635 7 703 105
No., 1973 I 427 396 120 943
GP 2561 3202 1701 7464
Ratio to population I 1:4 885 1:8 695 1:18 113 1:8 168
GP 1:814 1:1 075 1:1 278 1:1 032
I :GP ratio 1:6 1:8 1:14 1:8
Table Il-Mean number of services provided by internists and mean annual payment to them by Ontario Health Insurance Plan (OHIP), 1973-74
Area Toronto Other medical-school Without medical schools Total/average
No. of internists billing OHIP 400 360 135 895
Mean no. of services per internist 8 106 7 053 10 156 8 438
Mean annual payment to each internist ($) 54 184 46 040 61156 53 793
Table IV-General characteristics of 694 internists*
Characteristic
Type of practice; no. (and % of total in each type) Consultant Mixed Nonclinical
Total no. (and % of 694)
Sex
*Data for those who returned incompletely answered questionnaires were excluded.
Table V-Distribution of subspecialists and general internists with a subspecialty interest Type of practice; no. of internists Consulting Mixed Subspecialty Subspecialty Subspecialty Subspecialty interest Total Subspecialty interest Total Cardiology 67 7 74 4 11 15 Hematology and oncology 45 8 53 3 7 10 Endocrinology and metabolism 38 9 47 5 11 16 Gastroenterology 41 4 45 2 4 6 Rheumatology 36 1 37 4 5 9 Respiratory disease 22 7 29 2 7 9 Allergy and immunology 27 1 28 2 4 6 Nephrology 14 5 19 4 5 9 Other 13 6 19 1 3 4 Total* 303 48 351 27 57 84 *Some had interests in more than one specialty and others quoted nonclinical specialties, such as medical insurance; hence the totals do not agree with those in Table IV.
fluenced strongly by what the respondents were currently doing. The distribution by subspecialty of subspecialists and general internists with a subspecialty interest is shown in Table V. The mean number of hours on call per week was approximately the same as the mean number of hours regularly worked for each type of practice (Table VI). Perception of future role of internists Over 100 internists commented, many at great length, on the future of internal medicine in Ontario. Many thought the general internist was tending to be "squeezed" between better trained general practitioners on the one hand and subspecialists on the other. A few were pessimistic about the future of the consulting general internist but most believed he had a useful role. A few thought the general internist had no place in university hospitals but should be the main medical specialist in community hospitals. Many more stated that general internists were under-represented in university hospitals and that this had bad effects on residency training. Several believed that subspecialists were not well enough trained in general internal medicine. I feel that the General Internist should have the longest period of training, 5 years, and do only referral practice. The subspecialist should have 4 years' training and be limited to referrals in his areas of specialty. The family physician should do primary care. Most were in favour of internists doing entirely referred work. It would seem futile to train an Internist who then becomes a primary care physician. The vast majority of cases presenting to a family doctor's office do not require the in depth knowledge that an Internist's training provides, making the physician frustrated and inevitably diluting his depth of knowledge. An Internist's training does not provide the background to deal with
gynecological, pediatric or surgical problems which enter a family doctor's of........ I believe the best primary care physician is a well trained, conscientious family doctor and he deserves every access to well trained specialists with whom to consult. O.H.I.P. should not pay Internists involved in primary care because it is unnecessary and expensive. Thus, as a taxpayer, I am paying for those who feel that they should have an Internist as a family physician and I resent this. Several who thought it theoretically undesirable for internists to do primary care cited economic reasons for their own primary care practice. Some others differentiated continuing primary care for the few difficult cases when this could reasonably be provided by an internist without a general practitioner. A number of respondents stated that there was an urgent need for manpower planning. To facilitate the possibility of all Internists doing referred work only, the number of Internists to be trained and certified should be related to the professions s requirements [for] such Internists. University Centres should be discouraged from hiring physicians to train in Internal Medicine in numbers exceeding the requirements for eventual certified internists. Medical residents should not be hired with the object of supplying sufficient manpower to University Hospitals with cynical disregard [for] the trainee's future prospects on completing training. Discussion Primary care and the internist is the subject of much discussion, particularly in the United States.48'14'. There is no doubt that most US internists provide primary care; Engstrom9 found that 77% of internists in Milwaukee. were family physicians, and Reitemeier and colleagues17 reported similar findings in a survey of former Mayo Clinic residents. Recently residency training in the
Table VI-Estimated number of hours worked and allocation of time*
Nature of work
Type of practice; mean no. (and standard deviation) of hours of work per week Private University Agency
Regular Patient care Teaching Research Administration Other Total On call (additional)
n=379 n=200 45.85 . 12.9 21.32 . 10.6 4.27 . 5.5 12.70 . 6.3 0.70 + 2.4 11.25 + 11.8 2.86 + 4.5 10.62 + 9.7 0.52 + 2.6 0.24 + 1.7 53.7 + 12.1 56.1 + 10.7 n = 358 n = 166 56.8 + 38.1 50.9 + 34.6 4This information was given by the numbers of respondents in parenthesis.
1272 CMA JOURNAL/JUNE 4, 1977/VOL. 116
n=39 19.18 i: 18.0 3.10 4.2 2.80 + 6.1 16.60 :1 16.0 2.75 + 7.8 44.4 + 11.8 n = 21 49.1 + 32.3
US has been altered to prepare internists for primary care.18'19 Goroll and associates19 described a primary-care program for internal medicine residents at the Massachusetts General Hospital that includes office gynecology, orthopedics, otorhinolaryngology, dermatology and psychiatry, a curriculum similar to that provided in most Canadian family-practice residencies. By contrast, in the United Kingdom it is assumed that internists will have entirely referral practices.". Comparison of British and North American data is difficult however; British hospitals virtually exclude general practitioners and have a proportionately very large number of residents."0 There are no published data on the practice of internal medicine in Canada. In 1966 Goldberg. reviewed medical manpower for all specialties in Canada; he did not give the geographic distribution or any information about the type of practice. Pediatric practice in Canada has been extensively investigated by Shah,".'" who demonstrated that 70% of Canadian pediatricians provided some primary care. However, several authors have discussed the theoretically appropriate pattern of practice for internists. Spaulding1 advocated a three-tier system in which all primary care would be provided by general practitioners, and internists would be confined to referrals, and in which tertiary subspecialty units would operate in major centres. Mustard and colleagues2 and the Ontario Council of Health28 also favoured entirely referral practice for specialists, and the latter discussed mechanisms for arriving at quotas for specialists. Despite the limited data available, attempts have also been made to predict future manpower requirements.11'28'31 The National Committee on Physician Manpower11 and its requirements subcommittee on internal medicine recommended a ratio of number of internists to population of approximately 1:8000 by 1981, compared with the present 1:9300. The working party also recommended increases in the production of internists.11 However, these recommendations did not take account of the increasing numbers of general practitioners in Canada, nor were they based on knowledge of practice patterns of internists. Our study provides some basic information on internists in Ontario, who in 1975 constituted 41% of all internists in Canada (975 of 2370). The questionnaire responses suggested that about two thirds of the internists in the province confined themselves to referral practice, and the age distribution indicated that this tendency would become stronger with time.
Since the pattern of practice in Ontario differs greatly from that in the US, there is no need to change residency training in Ontario to prepare trainees for primary care, as advocated by Goroll and colleagues"9 for the US. The present Ontario curricula are confined to internal medicine and its subspecialties and this seems broadly appropriate to what most internists are now doing. Implementation of wholly referral practice for internists, as recommended by Spaulding' and Mustard and associates,' seems feasible, involving major changes for only a third of present internists. If such should be done, manpower policy would need to be carefully planned and a quota system for internists in relation to population would be inevitable. Because about one third of internists are providing a substantial amount of primary care there is probably a surplus of internists in Ontario at present. Residency programs should probably aim to produce fewer, more highly trained internists, who would be able to compete successfully as consultants. The Ontario Council of Health has recommended quotas for the various specialties,28 although this seems unlikely to occur voluntarily. Our data on the distribution of internists and general practitioners and the number of services provided by the former (Tables I and II) suggest no fixed relation based on a predictable volume of work. The large number of services provided in Toronto may be partly due to greater complexity of cases but could also be interpreted as supporting Baltzan's32 hypothesis that the number of services. in a given area is mainly a function of the number of practitioners there. In areas with high ratios of number of internists to population some internists will provide primary care. To determine fair quotas for internists would require data from areas where a consulting pattern of practice has already emerged, taking into account the varying hospital privileges of general practitioners and introducing an equitable mechanism for the appointment of "new" internists in a community. We thank the physicians of Ontario who financed this project through the Physicians' Services Incorporated Foundation,
and several colleagues who assisted us in drawing up the questionnaire. We are also grateful to Mr. B. Swami for technical help, Mr. A. Post and Mr. G. Smith of Peel Memorial Hospital for administrative services, and Mrs. R. Pembry for typing the manuscript. We are indebted to Dr. D.A. Davidson and the Ontario Medical Association for their generous help in distributing the questionnaires, and the medical publications department of the Hospital for Sick Children, Toronto, for help with the manuscript.
References 1. SPAULDING WB: The role of the general internist. Ann R Coll Physicians Surg Can 6: 99, 1973 2. MUSTARD JF (chmn): Report of the Health Planning Task Force, Ontario Ministry of Health, research and analysis division, Toronto, Queen's Printer, 1974 3. MCCONNON JK: The intra- and extra-professionals: internal medicine in Canada. Ann R Coll Physicians Surg Can 7: 127, 1974 4. BERRY MG: Internal medicine, 1974. Bull Am Coll Physicians 15: 9, 1974 5. SCHNABEL TG: The A.C.P. president looks at internal medicine. Ibid, p 5 6. ROSENOW EC: Primary medical care. lbid, p 3 7. WILLARD WF (chmn): Meeting the Challenge of Family Practice, report of the ad hoc committee on education for family practice, Chicago, Am Med Assoc, Sept 1966 8. MILLIS JS (chmn): The Graduate Education of Physicians, report of the citizen's commission on graduate medical education, Chicago, Am Med Assoc, Aug 1966 9. ENGSTROM WW: Are internists functioning as family physicians? Ann Intern Med 66: 613, 1967 10. BURNUM JF: What one internist does in his practice. Implications for the internist's disputed role and education. Ann Intern Med 78: 437, 1973 11. SPAULDING WB (chmn): Requirements for Physicians in Canada, Report of the Working Party in Internal Medicine to the Requirements Committee on Physician Manpower, National Committee on Physician Manpower, Ottawa, Health and Welfare Canada, 1974/75 12. Ontario Medical Directory - 1973, Toronto, College of Physicians and Surgeons of Ontario, 1973 13. Ontario Medical Directory - 1975, Toronto, College of Physicians and Surgeons of Ontario, 1975 14. YOUNG LE: The broadly based internist as the backbone of medical practice, in Controversy in Internal Medicine II, INGELFINGER FJ, EBERT RV, FINLAND M, et al (eds), Philadelphia, Saunders, 1974, pp 51-63 15. PELLEGRINO ED: The identity crisis of an ideal, ibid, pp 41-50
16. PETERSDORF R: Issues in primary care: the academic perspective. J Med Educ 50: 5, 1975 17. REITEMEIER RJ, SPITTELL JA JR, WEEKS RE, et al: Participation by internists in primary care. Results of a survey of Mayo clinical alumni. Arch Intern Med 135: 255, 1975 18. EBERT RV: Training of the internist as a primary physician. Ann Intern Med 76: 653, 1972 19. GOROLL AH, STOECKLE JD, GOLDFINGER SE, et al: Residency training in primary care internal medicine. Report of an operational program. Ann Intern Med 83: 872, 1975 20. Medical staffing in the National Health Service in England and Wales. Lancet 1: 944, 1970 21. Great Britain, Department of Health and Social Security: Population and Vital Statistics for England, 1974, London, HMSO, 1974, pp 11-57 22. BEESON PB: Some good features of the British National Health Service. J Med Educ 49: 43, 1974 23. LOUDON IS: A question of numbers. Lancet 1: 736, 1976 24. HOPKINS A: Consultants' work load (C). Ibid, p 956 25. GOLDBERG WM: The present manpower situation with regard to specialists in Canada. Can Med Assoc J 97: 1578, 1967 26. SHAH CP: The Canadian pediatrician: a dilemma in child health. Can Med Assoc J 105: 1059, 1971 27. Idem: Time and money in pediatric practice. Can Med Assoc J 110: 530, 1974 28. Physician Manpower, report of the Ontario Council of Health, senior advisory body to the minister of health, 1974, Toronto, Ontario Council of Health, 1974 29. GUNTON RW: Manpower needs in internal medicine. Ann R Coll Physicians Surg Can 6: 136, 1973 30. KoRcOK M: Ontario medical manpower study shows plenty of MDs but shortages in most specialties. Can Med Assoc J 114: 154, 1976 31. KORCOK M, GEEKIE DA: Report issued by requirements subcommittee of National Committee on Physician Manpower. Can Med Assoc J 115: 265, 1976 32. BALTZAN MA: Medical care costs cc physician manpower: a new economic theory. Can Med Assoc 1 108: 101, 1973
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To determine the feasibility of wholly referral practice In Internal medicine within a prepaid health service, the practice profiles of 694 InternIsts in metropolitan, nonmetropolitan urban, and rural areas of Ontario were delineated by analysis of data from questionnaires and health-insurance billing. The questionnaire showed that two thirds of internists, chiefly younger practitioners, confined themselves to a referral consultant practice; the other one third included primary care. Subspeciallsts practised predominantly in metropolitan areas; most general internists in such areas provided primary care, whereas most general internists elsewhere had an entirely referral practice. This pattern of practice is greatly different from that in the United States but probably similar to that in other provinces in Canada. Extension of wholly referral practice to all Internists in Ontario appears feasible, provided the numbers entering residency training are controlled. The present Ontario curricula for internal medicine and its subspecialties appear suitable for such a pattern of practice.
avalent une pratique enti.rement composee de consultation sur reference. Ce sch6ma de pratique est sensiblement different de celui rencontr. aux .tats.Unis, mais ii est probablement semblable a celul des autres provinces du Canada. L.extension a tous les internistes de l.Ontario d.une pratique de consultation sur reference seulement semble r6alisable en autant que le nombre de medecins residents solt contr8le. Le pr6sent curriculum exige en Ontario pour Ia m6decine interne et ses sous-specialites semble se pr.ter a une telle pratique.
areas without medical schools, including some cities. We analysed OHIP billing data for 1972-73 and 1973-74 to determine the mean number of services provided by, and annual payment to, internists in the three areas. A service was defined as any single item, varying from consultation or minor assessment to a specific procedure, such as electrocardiography. We applied the fee-schedule terms used by OHIP, in some cases combining categories for simplicity. Definitions were as follows: Consultation (including reconsultation): referral of a patient to another physician for a written opinion. General assessment (including Formulating plans for residency train- sessment): full medical history reasand ing in internal medicine in Canada is complete examination; not necessarily a difficult because of uncertainty about referral. the theoretically desirable pattern of Specific assessment (including practice for internists and the lack of sessment): history relating to, andreasexdata on present practices. Some have amination of, any part, region or syssuggested that specialists in Canada tem; not necessarily a referral. should have referral practices only,1-3 Minor or partial assessment, or subas in Britain, whereas American authors sequent visit, or both: not necessarily advocate primary care as a major role a referral. of the internist.4-10 To determine whethLaboratory tests and procedures: (a) er changes are needed requires knowl- diagnostic radiology, including edge of current practice, as is evident medicine investigation and testsnuclear from the report of the National Com- times performed by internists some(e.g., Afin de determiner Ia possibilit6 d'une mittee on Physician Manpower in pratique de medecine interne compos6e Canada.11 We therefore questioned fluoroscopy and angiography); (b) manual tests (e.g., routine extotalement de patients r6f6r6s a practising internists in Ontario and amination of 24-hour urinalysis, collection of lint6rieur d'un service de soins de studied their billing to the Ontario urine for 1 7-hydroxycorticosteroids and sante pay6 d.avance, les types de Health Insurance Plan (OHIP). interpretation of bone marrow films); pratique de 694 internistes des (c) automated tests; and (d) radioisotope r6gions metropolitalnes, urbaines Methods therapy. nonmetropolitaines, et rurales de Procedures: (a) nonsurgical (e.g., l'Ontario ont ete etablis par l.analyse Distribution and workload of internists cervical smear); (b) surgical (e.g., colonde donnees recuelilies par questionnaire oscopy polypectomy); (c) specific et de celles obtenues a partir du To derive ratios of population to internal and medicine procedures (e.g., systeme de facturation de l'assurance number of internists (excluding neurol- pleural tap and arterial blood-gas sante. ogists) and to number of general pracLe questionnaire a r6v616 que deux titioners, we defined a general practi- sampling); and (d) electrocardiography. tiers des internistes, les medecins tioner as a physician without specialist les plus jeunes surtout, se limitalent qualification from the Royal College Profiles of internists a une pratique de consultation sur of Physicians and Surgeons of Canada. A questionnaire was sent to the 975 ref6rence; I.autre tiers offrait aussi We determined the numbers of intern- internists listed in the 1975 "Ontario les premiers soins. Les internistes ists and general practitioners from the Medical Directory"13 asking sex, age, offrant une sous-specialisation 1973 "Ontario Medical Directory". date of certification and number of pratiquaient principalement en region and derived ratios to the general pop- years of practice; country of graduametropolitaine; les internistes generaux ulation from the latest available (1971) tion and of graduate training; geode ces regions offraient les premiers Government of Canada census. graphic location of practice (metroposoins, alors que Ia plupart des Ontario has a population of over 7 litan [within the boundaries of the five Internistes g6neraux des autres regions million; nearly all residents are covered university cities] or nonmetropolitan); by OHIP. OHIP divides the province type of practice (70% or more of into nine units: Toronto (population, workload in private practice, university over 2 million), including surrounding appointment or agency practice); and From the departments of medicine, preventive districts, which has the largest medical nature of practice (primary care, remedicine and biostatistics, and health administration, University of Toronto; Peel school in Ontario; four other medical- ferred work in internal medicine or a Memorial Hospital, Brampton; and the Hospital for Sick Children, Toronto school areas, including the cities subspecialty, or continuing care for (Hamilton, Kingston, London and Ot- chronic conditions with or without the Reprint requests to: Dr. J.K. McConnun, 164 Queen St., Brampton, Ont. L6V 1B4 tawa) and surrounding areas; and four help of a general practitioner) and the CMA JOURNAL/JUNE 4, 1977/VOL. 116
1269
Table I-Ratios of numbers of internists (I) and general practitioners (GP) to population, and l:GP ratio, OntarIo, 1973
Area Toronto Other medical-school Without medical schools Total/average
Population, 1971 2 086 020 3 443 450 2 173 635 7 703 105
No., 1973 I 427 396 120 943
GP 2561 3202 1701 7464
Ratio to population I 1:4 885 1:8 695 1:18 113 1:8 168
GP 1:814 1:1 075 1:1 278 1:1 032
I :GP ratio 1:6 1:8 1:14 1:8
Table Il-Mean number of services provided by internists and mean annual payment to them by Ontario Health Insurance Plan (OHIP), 1973-74
Area Toronto Other medical-school Without medical schools Total/average
No. of internists billing OHIP 400 360 135 895
Mean no. of services per internist 8 106 7 053 10 156 8 438
Mean annual payment to each internist ($) 54 184 46 040 61156 53 793
Table IV-General characteristics of 694 internists*
Characteristic
Type of practice; no. (and % of total in each type) Consultant Mixed Nonclinical
Total no. (and % of 694)
Sex
*Data for those who returned incompletely answered questionnaires were excluded.
Table V-Distribution of subspecialists and general internists with a subspecialty interest Type of practice; no. of internists Consulting Mixed Subspecialty Subspecialty Subspecialty Subspecialty interest Total Subspecialty interest Total Cardiology 67 7 74 4 11 15 Hematology and oncology 45 8 53 3 7 10 Endocrinology and metabolism 38 9 47 5 11 16 Gastroenterology 41 4 45 2 4 6 Rheumatology 36 1 37 4 5 9 Respiratory disease 22 7 29 2 7 9 Allergy and immunology 27 1 28 2 4 6 Nephrology 14 5 19 4 5 9 Other 13 6 19 1 3 4 Total* 303 48 351 27 57 84 *Some had interests in more than one specialty and others quoted nonclinical specialties, such as medical insurance; hence the totals do not agree with those in Table IV.
fluenced strongly by what the respondents were currently doing. The distribution by subspecialty of subspecialists and general internists with a subspecialty interest is shown in Table V. The mean number of hours on call per week was approximately the same as the mean number of hours regularly worked for each type of practice (Table VI). Perception of future role of internists Over 100 internists commented, many at great length, on the future of internal medicine in Ontario. Many thought the general internist was tending to be "squeezed" between better trained general practitioners on the one hand and subspecialists on the other. A few were pessimistic about the future of the consulting general internist but most believed he had a useful role. A few thought the general internist had no place in university hospitals but should be the main medical specialist in community hospitals. Many more stated that general internists were under-represented in university hospitals and that this had bad effects on residency training. Several believed that subspecialists were not well enough trained in general internal medicine. I feel that the General Internist should have the longest period of training, 5 years, and do only referral practice. The subspecialist should have 4 years' training and be limited to referrals in his areas of specialty. The family physician should do primary care. Most were in favour of internists doing entirely referred work. It would seem futile to train an Internist who then becomes a primary care physician. The vast majority of cases presenting to a family doctor's office do not require the in depth knowledge that an Internist's training provides, making the physician frustrated and inevitably diluting his depth of knowledge. An Internist's training does not provide the background to deal with
gynecological, pediatric or surgical problems which enter a family doctor's of........ I believe the best primary care physician is a well trained, conscientious family doctor and he deserves every access to well trained specialists with whom to consult. O.H.I.P. should not pay Internists involved in primary care because it is unnecessary and expensive. Thus, as a taxpayer, I am paying for those who feel that they should have an Internist as a family physician and I resent this. Several who thought it theoretically undesirable for internists to do primary care cited economic reasons for their own primary care practice. Some others differentiated continuing primary care for the few difficult cases when this could reasonably be provided by an internist without a general practitioner. A number of respondents stated that there was an urgent need for manpower planning. To facilitate the possibility of all Internists doing referred work only, the number of Internists to be trained and certified should be related to the professions s requirements [for] such Internists. University Centres should be discouraged from hiring physicians to train in Internal Medicine in numbers exceeding the requirements for eventual certified internists. Medical residents should not be hired with the object of supplying sufficient manpower to University Hospitals with cynical disregard [for] the trainee's future prospects on completing training. Discussion Primary care and the internist is the subject of much discussion, particularly in the United States.48'14'. There is no doubt that most US internists provide primary care; Engstrom9 found that 77% of internists in Milwaukee. were family physicians, and Reitemeier and colleagues17 reported similar findings in a survey of former Mayo Clinic residents. Recently residency training in the
Table VI-Estimated number of hours worked and allocation of time*
Nature of work
Type of practice; mean no. (and standard deviation) of hours of work per week Private University Agency
Regular Patient care Teaching Research Administration Other Total On call (additional)
n=379 n=200 45.85 . 12.9 21.32 . 10.6 4.27 . 5.5 12.70 . 6.3 0.70 + 2.4 11.25 + 11.8 2.86 + 4.5 10.62 + 9.7 0.52 + 2.6 0.24 + 1.7 53.7 + 12.1 56.1 + 10.7 n = 358 n = 166 56.8 + 38.1 50.9 + 34.6 4This information was given by the numbers of respondents in parenthesis.
1272 CMA JOURNAL/JUNE 4, 1977/VOL. 116
n=39 19.18 i: 18.0 3.10 4.2 2.80 + 6.1 16.60 :1 16.0 2.75 + 7.8 44.4 + 11.8 n = 21 49.1 + 32.3
US has been altered to prepare internists for primary care.18'19 Goroll and associates19 described a primary-care program for internal medicine residents at the Massachusetts General Hospital that includes office gynecology, orthopedics, otorhinolaryngology, dermatology and psychiatry, a curriculum similar to that provided in most Canadian family-practice residencies. By contrast, in the United Kingdom it is assumed that internists will have entirely referral practices.". Comparison of British and North American data is difficult however; British hospitals virtually exclude general practitioners and have a proportionately very large number of residents."0 There are no published data on the practice of internal medicine in Canada. In 1966 Goldberg. reviewed medical manpower for all specialties in Canada; he did not give the geographic distribution or any information about the type of practice. Pediatric practice in Canada has been extensively investigated by Shah,".'" who demonstrated that 70% of Canadian pediatricians provided some primary care. However, several authors have discussed the theoretically appropriate pattern of practice for internists. Spaulding1 advocated a three-tier system in which all primary care would be provided by general practitioners, and internists would be confined to referrals, and in which tertiary subspecialty units would operate in major centres. Mustard and colleagues2 and the Ontario Council of Health28 also favoured entirely referral practice for specialists, and the latter discussed mechanisms for arriving at quotas for specialists. Despite the limited data available, attempts have also been made to predict future manpower requirements.11'28'31 The National Committee on Physician Manpower11 and its requirements subcommittee on internal medicine recommended a ratio of number of internists to population of approximately 1:8000 by 1981, compared with the present 1:9300. The working party also recommended increases in the production of internists.11 However, these recommendations did not take account of the increasing numbers of general practitioners in Canada, nor were they based on knowledge of practice patterns of internists. Our study provides some basic information on internists in Ontario, who in 1975 constituted 41% of all internists in Canada (975 of 2370). The questionnaire responses suggested that about two thirds of the internists in the province confined themselves to referral practice, and the age distribution indicated that this tendency would become stronger with time.
Since the pattern of practice in Ontario differs greatly from that in the US, there is no need to change residency training in Ontario to prepare trainees for primary care, as advocated by Goroll and colleagues"9 for the US. The present Ontario curricula are confined to internal medicine and its subspecialties and this seems broadly appropriate to what most internists are now doing. Implementation of wholly referral practice for internists, as recommended by Spaulding' and Mustard and associates,' seems feasible, involving major changes for only a third of present internists. If such should be done, manpower policy would need to be carefully planned and a quota system for internists in relation to population would be inevitable. Because about one third of internists are providing a substantial amount of primary care there is probably a surplus of internists in Ontario at present. Residency programs should probably aim to produce fewer, more highly trained internists, who would be able to compete successfully as consultants. The Ontario Council of Health has recommended quotas for the various specialties,28 although this seems unlikely to occur voluntarily. Our data on the distribution of internists and general practitioners and the number of services provided by the former (Tables I and II) suggest no fixed relation based on a predictable volume of work. The large number of services provided in Toronto may be partly due to greater complexity of cases but could also be interpreted as supporting Baltzan's32 hypothesis that the number of services. in a given area is mainly a function of the number of practitioners there. In areas with high ratios of number of internists to population some internists will provide primary care. To determine fair quotas for internists would require data from areas where a consulting pattern of practice has already emerged, taking into account the varying hospital privileges of general practitioners and introducing an equitable mechanism for the appointment of "new" internists in a community. We thank the physicians of Ontario who financed this project through the Physicians' Services Incorporated Foundation,
and several colleagues who assisted us in drawing up the questionnaire. We are also grateful to Mr. B. Swami for technical help, Mr. A. Post and Mr. G. Smith of Peel Memorial Hospital for administrative services, and Mrs. R. Pembry for typing the manuscript. We are indebted to Dr. D.A. Davidson and the Ontario Medical Association for their generous help in distributing the questionnaires, and the medical publications department of the Hospital for Sick Children, Toronto, for help with the manuscript.
References 1. SPAULDING WB: The role of the general internist. Ann R Coll Physicians Surg Can 6: 99, 1973 2. MUSTARD JF (chmn): Report of the Health Planning Task Force, Ontario Ministry of Health, research and analysis division, Toronto, Queen's Printer, 1974 3. MCCONNON JK: The intra- and extra-professionals: internal medicine in Canada. Ann R Coll Physicians Surg Can 7: 127, 1974 4. BERRY MG: Internal medicine, 1974. Bull Am Coll Physicians 15: 9, 1974 5. SCHNABEL TG: The A.C.P. president looks at internal medicine. Ibid, p 5 6. ROSENOW EC: Primary medical care. lbid, p 3 7. WILLARD WF (chmn): Meeting the Challenge of Family Practice, report of the ad hoc committee on education for family practice, Chicago, Am Med Assoc, Sept 1966 8. MILLIS JS (chmn): The Graduate Education of Physicians, report of the citizen's commission on graduate medical education, Chicago, Am Med Assoc, Aug 1966 9. ENGSTROM WW: Are internists functioning as family physicians? Ann Intern Med 66: 613, 1967 10. BURNUM JF: What one internist does in his practice. Implications for the internist's disputed role and education. Ann Intern Med 78: 437, 1973 11. SPAULDING WB (chmn): Requirements for Physicians in Canada, Report of the Working Party in Internal Medicine to the Requirements Committee on Physician Manpower, National Committee on Physician Manpower, Ottawa, Health and Welfare Canada, 1974/75 12. Ontario Medical Directory - 1973, Toronto, College of Physicians and Surgeons of Ontario, 1973 13. Ontario Medical Directory - 1975, Toronto, College of Physicians and Surgeons of Ontario, 1975 14. YOUNG LE: The broadly based internist as the backbone of medical practice, in Controversy in Internal Medicine II, INGELFINGER FJ, EBERT RV, FINLAND M, et al (eds), Philadelphia, Saunders, 1974, pp 51-63 15. PELLEGRINO ED: The identity crisis of an ideal, ibid, pp 41-50
16. PETERSDORF R: Issues in primary care: the academic perspective. J Med Educ 50: 5, 1975 17. REITEMEIER RJ, SPITTELL JA JR, WEEKS RE, et al: Participation by internists in primary care. Results of a survey of Mayo clinical alumni. Arch Intern Med 135: 255, 1975 18. EBERT RV: Training of the internist as a primary physician. Ann Intern Med 76: 653, 1972 19. GOROLL AH, STOECKLE JD, GOLDFINGER SE, et al: Residency training in primary care internal medicine. Report of an operational program. Ann Intern Med 83: 872, 1975 20. Medical staffing in the National Health Service in England and Wales. Lancet 1: 944, 1970 21. Great Britain, Department of Health and Social Security: Population and Vital Statistics for England, 1974, London, HMSO, 1974, pp 11-57 22. BEESON PB: Some good features of the British National Health Service. J Med Educ 49: 43, 1974 23. LOUDON IS: A question of numbers. Lancet 1: 736, 1976 24. HOPKINS A: Consultants' work load (C). Ibid, p 956 25. GOLDBERG WM: The present manpower situation with regard to specialists in Canada. Can Med Assoc J 97: 1578, 1967 26. SHAH CP: The Canadian pediatrician: a dilemma in child health. Can Med Assoc J 105: 1059, 1971 27. Idem: Time and money in pediatric practice. Can Med Assoc J 110: 530, 1974 28. Physician Manpower, report of the Ontario Council of Health, senior advisory body to the minister of health, 1974, Toronto, Ontario Council of Health, 1974 29. GUNTON RW: Manpower needs in internal medicine. Ann R Coll Physicians Surg Can 6: 136, 1973 30. KoRcOK M: Ontario medical manpower study shows plenty of MDs but shortages in most specialties. Can Med Assoc J 114: 154, 1976 31. KORCOK M, GEEKIE DA: Report issued by requirements subcommittee of National Committee on Physician Manpower. Can Med Assoc J 115: 265, 1976 32. BALTZAN MA: Medical care costs cc physician manpower: a new economic theory. Can Med Assoc 1 108: 101, 1973
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